[Intrahepatic Hematoma and Pulmonary Embolism in a Young Woman with Oral Contraceptives Complicated by Type II Heparin Induced Thrombocytopenia Requiring ECMO-Therapy: a Case Report]

Abstract

A 46-year-old woman on oral contraceptives developed an intrahepatic hematoma due to a benign hepatic tumor. As an incidental finding, a computed tomography showed a pulmonary embolism. Unfractionated heparin was given in a prophylactic dosing in an attempt to balance the risk of further intrahepatic bleeding with that of thrombosis. Ten days later, the patient developed a second pulmonary embolism along with acute right heart failure requiring cardiopulmonary resuscitation. As a sufficient circulation and oxygenation could not be reestablished, a veno-arterial extracorporeal membrane oxygenation (ECMO) was installed. An ELISA-Test, detecting PF4-Heparin associated antibodies, resulted in a positive result for a type II heparin induced thrombocytopenia even in the absence of thrombocytopenia. After hemodynamic and pulmonary stabilization, six days after ECMO-support the cannula was scheduled to be removed. On removal of the venous cannula the patient developed another massive pulmonary embolism with cardiac arrest which led to immediate reinstallation of va-ECMO. Under therapeutic anticoagulation using argatroban the ECMO support continued until the patient was on day 17 successfully weaned.